Federal Aviation Administration Beyond Pilot Error: Aviation Safety and Training Kathy H Abbott,...

Federal AviationAdministrationBeyond Pilot Error:

Aviation Safety and Training

Kathy H Abbott, PhD, FRAeSFederal Aviation Administration

Capt. John M. Cox, FRAeSSafety Operating Systems

27 April 2010

2Federal AviationAdministration

Beyond Pilot Error: Aviation Safety and TrainingWATS27 April 2010

Pilots Are Unique People



Old View New View• Human error is the

cause of accidents• Human is the most

unreliable component• Improve safety by

restricting human action

• Human error is the effect of deeper issues

• Human is necessary to create safety

• Improve safety by understanding (and leveraging) human performance

From Dekker 2002

Human Error and Aviation Safety

Federal AviationAdministration

Risk Mitigation – Where?

Designer Error

PilotDesign Engineer

Envelope Protection

TCAS/ACAS

Flight Director

Pilot Error

Flexibility/Adaptability

Cat IIIAutoland

Circling Approaches



Overview

• Flight Path Management and Flight Deck Automation – where can training be improved?

• WHY do errors occur? • Looking beyond error at the “sharp end”



Flight Path Management and Flight Deck Automation – where can training be improved?• Performance-based Operations Aviation

Rulemaking Committee (PARC) and Commercial Aviation Safety Team (CAST) PARC/CAST (preliminary results)

• FAA International Rudder Survey• Recent accidents/incidents



Flight Deck Automation Working Group

• Joint under the Performance-based Operations Aviation Rulemaking Committee (PARC) and Commercial Aviation Safety Team (CAST)

• Current design, training and use of flight path management systems in transport airplanes in “121-like” operations

• Preliminary results from:– 734 incidents from Aviation Safety Reporting System (ASRS)

within scope– 46 major incidents and accident reports within scope– normal ops via Line Operations Safety Audit (LOSA)



X X XXX

X X



Potential Areas for ImprovedPilot Training• Manual handling• Flight path management systems• Unusual attitude avoidance, recognition

and recovery• Speed and energy management• Use of rudder• Managing malfunctions• Managing distractions• Crew coordination and communication



Turkish Airlines Flight TK 1951



Pilot

Equipment design, training, procedures

OrganizationRegulatory

Accident

Legal

Adapted from Reason



Legal

Federal AviationAdministration

Regulatory



Organization



Equipment Design Training Procedures



Pilot



Pilot

Equipment design, training, procedures

OrganizationRegulatory

Accident

Legal

Data Collection?Investigations?Training?



Operators, Regulators, Manufacturers, Training Organizations…

It is about training all the people



Old View New View Revised• Human error is the

cause of accidents• Human is the most

unreliable component• Improve safety by

restricting human action

• Human error is the effect of deeper issues

• Human is necessary to create safety

• Get away from blame and ask “why”?

• Improve safety by understanding (and leveraging) human and organizational performance

Human Error and Aviation Safety



Thank You

Federal Aviation Administration Beyond Pilot Error: Aviation Safety and Training Kathy H Abbott,...

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